Citation Nr: 1311410 Decision Date: 04/05/13 Archive Date: 04/19/13 DOCKET NO. 06-39 006 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for defective vision. 2. Entitlement to service connection for a right hand disorder, other than involving the right index finger. 3. Entitlement to service connection for carpal tunnel syndrome (CTS), also claimed as right wrist pain due to wrist surgery, including as secondary to the right hand or wrist disorder. 4. Entitlement to service connection for residuals of an injury to the right index finger. 5. Entitlement to service connection for residuals of an injury to the right little finger. 6. Entitlement to a rating higher than 30 percent for the migraine headaches with history of tension headaches. 7. Entitlement to an effective date earlier than November 8, 2007, for the award of the 30 percent rating for the migraine headaches with history of tension headaches. 8. Entitlement to a rating higher than 20 percent for degenerative disc disease (DDD) of the lumbar spine. WITNESS AT HEARING ON APPEAL The Appellant ATTORNEY FOR THE BOARD H. Bunker, Associate Counsel INTRODUCTION The Veteran had active military service from April 1984 to July 2004. This appeal to the Board of Veterans' Appeals (Board/BVA) is from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). A rating decision in September 2005, in pertinent part, granted service connection for a low back disorder, now characterized as DDD of the lumbar spine, which was evaluated as 20-percent disabling, and for migraine headaches, evaluated as 10-percent disabling. That September 2005 rating decision denied additional claims of entitlement to service connection for defective vision and status post right index finger injury deformity. In an April 2008 rating decision, the RO also denied claims of entitlement to service connection for right hand CTS and a right hand disorder other than involving the right index finger. As well, the RO reduced from 20 to 10 percent the rating for the DDD of the Veteran's lumbar spine, retroactively effective from November 8, 2007, but an October 2009 decision since issued reinstated the 20 percent rating for this disability as of that same date. The Veteran testified at a hearing in July 2010 at the Board's offices in Washington, DC (Central Office (CO) hearing). In late March 2011, the Board contacted the Veteran by letter to clarify the issues on appeal since the two increased-rating claims that were on appeal to the Board were not addressed during his July 2010 hearing. He responded in April 2011, indicating he was indeed appealing these two increased-rating claims, as well as the others mentioned, and that he did not want a hearing concerning these two additional increased-rating claims. The Board subsequently, in July 2011, remanded the claims to the RO via the Appeals Management Center (AMC) to have the Agency of Original Jurisdiction (AOJ) further assist the Veteran in developing his claims, including by affording him VA compensation examinations. He had these VA compensation examinations in August and October 2011 for the claims concerning his vision, right hand, right index finger, migraines, and DDD of his lumbar spine. The examination reports are responsive to the questions the Board posed in its remand of these claims and provide the information needed to adjudicate these claims. Thus, there was compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). An October 2012 rating decision since issued on remand granted service connection for a left ankle disability. The Veteran has not, in response, separately appealed either the initial ratings assigned for this disability or the effective dates. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (Where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement (NOD) thereafter must be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or effective date.). So that claim is no longer at issue. The issues of entitlement to service connection for residuals of a right little finger injury, entitlement to an effective date earlier than November 8, 2007, for the assignment of a 30 percent rating for the migraine headaches, and entitlement to a rating higher than 30 percent for the migraine headaches are being REMANDED to the RO via the AMC for further development and consideration. Whereas the Board, instead, is going ahead and deciding the remaining claims. FINDINGS OF FACT 1. The competent and credible evidence of record does not indicate the Veteran has a ratable vision disorder or any associated disability as a result or consequence of his military service. 2. His claimed right hand disorder, CTS, and residuals of a right index finger injury are not shown to be due to any event or incident of his military service. 3. Throughout the appeal period his lumbar spine disability has involved limitation of motion with pain; there have not however been incapacitating episodes having a total duration of at least four weeks in a twelve-month period. 4. But his service-connected lumbar spine disability also has caused progressive neuropathy of his extremities; characterized at most by what amounts to mild incomplete paralysis, which therefore warrants a separate, additional, rating as an associated objective neurological abnormality. CONCLUSIONS OF LAW 1. A chronic, ratable, vision disorder was not incurred in or aggravated by his active military service. 38 U.S.C.A. §§ 1110, 1131, 1153, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2012). 2. The claimed right hand disorder, CTS, and residuals of a right index finger injury are not due to disease or injury incurred in or aggravated by his military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2012). 3. The criteria for a rating higher than 20 percent for his lumbar spine disability have not been met at any time during the appeal period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237, General Rating Formula for Diseases and Injuries of the Spine (2012). 4. Separate, additional, 10 percent ratings are warranted, however, because he has associated progressive neuropathy of his extremities, so including his lower extremities, which is proximately due to or the result of his service-connected lumbar spine disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310, 4.124a, Diagnostic Codes 8515 and 8520 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In deciding these claims, the Board has reviewed all of the evidence in the Veteran's claims file, both his physical claims file and electronic ("Virtual VA") file. Although the Board has an obligation to review the entire record, the Board does not have to discuss each and every piece of evidence reviewed, certainly not in exhaustive detail. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). He therefore must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to him). It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, this doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists that does not satisfactorily prove or disprove the claim. Reasonable doubt is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. The Veterans Claims Assistance Act (VCAA) The VCAA describes VA's duties to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Since the Board in effect is granting entitlement to service connection for progressive neuropathy of the extremities on the premise that it is associated with the already service-connected low back disability, meaning a symptom or manifestation of the low back disability and therefore deserving to be compensated as part and parcel of this disability, this amounts to a partial grant rather than entire denial of the claim concerning the rating for the low back disability. The notice requirements for the Veteran's claims of entitlement to service connection for a right hand disorder and CTS and his claim for an increased rating were met by way of letters sent to him in July and October 2007. The letters advised him of the type of information and evidence needed to substantiate these claims and of his and VA's respective obligations in obtaining specified types of evidence supporting these claims. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b). The letters also advised him of how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). While he was not provided 38 U.S.C.A. § 5103(a) notice prior to the September 2005 rating decision adjudicating his claims for a vision disorder and for residuals of a right index finger injury, the Board finds that providing him notice concerning these claims in a subsequent June 2006 letter, followed by readjudication of these claims in the December 2008, October 2009, and September 2012 supplemental statements of the case (SSOCs), served to rectify ("cure") the timing defect in the provision of the notice. When the RO does not provide notice prior to initially adjudicating a claim, or if the notice provided was inadequate or incomplete, VA only needs to provided all necessary notice and then readjudicate the claim, such as in a statement of the case (SOC) or supplemental SOC (SSOC), to rectify or "cure" the timing defect in the provision of the notice and preserve, rather than frustrate, its intended purpose in that the Veteran still has ample opportunity to participate effectively in the adjudication of his claim. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Moreover, as concerning the increased-rating claims, in Vasquez-Flores v. Peake, 22 Vet. App. 37 (2008), the U. S. Court of Appeals for Veterans Claims (Court/CAVC) clarified VA's notice obligations in these type claims. But on appeal the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court) vacated the lower Court's holding, indicating "generic" VCAA notice is all that is required, so VA does not have to notify a Veteran of alternative diagnostic codes (DCs) or potential "daily life" evidence. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Additionally, the Board finds that even if the above letters failed to provide the Veteran with adequate 38 U.S.C.A. § 5103(a) notice, this notice problem does not constitute prejudicial error in this case because the record reflects that a reasonable person could be expected to understand what was needed to substantiate the claims after reading the above letters as well as the rating decision, SOC, and SSOCs. Actual knowledge is established by statements or actions by the claimant or the claimant's representative demonstrating an awareness of what is necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007). In Shinseki v. Sanders, 129 S. Ct. 1696 (2009), the U. S. Supreme Court made clear that VCAA notice errors, even if shown to have occurred, are not presumptively prejudicial, rather, must be judged on a case-by-case basis. Moreover, as the pleading party attacking the agency's decision, the Veteran, not VA, has this burden of proof of not only establishing error, but also, above and beyond that, of showing how it is unduly prejudicial, meaning outcome determinative of his claim. There is no such pleading or allegation in this instance. As concerning the additional duty to assist the Veteran in developing the facts and evidence concerning his claims, the Board sees that his service treatment records (STRs) and post-service VA evaluation and treatment records are in the file. VA also obtained private treatment records and associated them with the claims file. To the extent that any records from the Andrews Air Force Base Medical Group could not be obtained, the Veteran was notified of this in October 2008 and did not provide any additional outstanding treatment records or suggest that any others exist that are obtainable. 38 C.F.R. § 3.159(c)(2), (c)(3), and (e)(1). Hence, the Board finds the duty to assist him in obtaining relevant medical records has been satisfied. The duty to assist also includes providing a medical examination or obtaining a medical opinion when necessary to make a decision on a claim. 38 U.S.C.A. § 5103A(d)(2) and 38 C.F.R. § 3.159(c)(4). The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of current or persistent or recurrent symptoms of disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred that would support incurrence or aggravation, (3) an indication that the current disability may be related to the event in service, but (4) insufficient evidence to decide the claim. When determining whether a VA examination and opinion are required under 38 U.S.C. § 5103A(d)(2), the law requires competent evidence of a disability or persistent or recurrent symptoms of a disability, but does not require competent evidence of a nexus, only that the evidence suggest an association between the disability and service or a service-connected disability. See Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). To this end, the Veteran was afforded VA medical examinations for his vision and hand disorder claims in August 2005, August 2011, and October 2011. Opinions resultantly were rendered by the examiners following their personal evaluations of him, including interview, and review of his claims file for his pertinent history. The examiners obtained an accurate history and listened to his assertions, both as concerning the etiologies of his claimed disabilities (in relation to the claims that are for service connection) and regarding the severity of his disabilities (as concerning the claims for higher ratings for the disabilities already determined to be service connected). The examiners laid a factual foundation and reasoned basis for their conclusions that were reached regarding these determinative issues. Therefore, the Board finds that the examinations are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (requiring that the Board ensure this adequacy). With regards to claims for increased ratings, where the evidence of record does not reflect the current state of the Veteran's disability, a new VA examination must be performed reassessing the severity of the disability. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a). To this end, the Veteran as mentioned was provided several VA medical examinations, most recently in August 2011, assessing and reassessing the severity of the DDD of his lumbar spine. The opinions rendered addressed the relevant rating criteria. There is no suggestion there has been a material change in the severity of his disability since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the mere passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. See also Palczewski v. Nicholson, 21 Vet. App. 174 (2007). Therefore, the Board finds that the examination concerning this disability also is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Consequently, the Board is satisfied that all relevant facts have been properly developed to the extent possible, and that no further notice or assistance to the appellant in developing the facts pertinent to these claims being decided is required. 38 U.S.C.A. §§ 5103 and 5103A; 38 C.F.R. § 3.159. Service Connection Service connection may be granted if it is shown the Veteran suffers from a disability resulting from an injury sustained or a disease contracted in the line of duty during his active military service, or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303(a), 3.306. Service connection on a direct-incurrence basis requires competent and credible evidence showing: (1) the Veteran has the alleged disability or, at the very least, indicating he has at some point since the filing of his claim; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002). That an injury or a disease occurred in service is not enough, as there also must be chronic (i.e., permanent) disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, or this is legitimately questionable, then a showing of continuity of symptomatology after service is required to support a finding of chronicity to link current disability to the disease or injury in service. 38 C.F.R. § 3.303(b). A recent decision of the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court), however, clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as "chronic" under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). One of the conditions identified as "chronic" under 38 C.F.R. § 3.309(a) is arthritis, so if it or any other condition identified in this VA regulation is manifested to a compensable degree (meaning to at least 10-percent disabling) within a year after the Veteran's discharge from service, then VA will presume the condition was incurred during his service. This presumption, however, is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Service connection also may be granted on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) and (b). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). Service connection may be granted for any injury or disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Vision Disorder The Veteran alleges he suffers from a vision disorder, including defective vision, as a result of numerous problems he experienced in service. These include a Vitamin-A deficiency, night blindness, getting sand in his eyes, cornea scarring, and as secondary to malaria medicine. See, e.g., August 2007, October 2007, and October 2008 statements. As discussed below, however, the Board does not find that service connection is warranted. During his entrance examination in March 1984 he was not diagnosed with any vision defects. In a November 1984 treatment record he reported that he had then recently injured his right eye during a football game. He was diagnosed with iritis of the right eye. In a January 1990 treatment record he was prescribed glasses to use as-needed for his vision deficits. In a June 1994 treatment record he stated that he had been hit in his right eye with a soccer ball. He was diagnosed with traumatic anterior uveitis. In March 1996 he was diagnosed with myopia of both eyes, with no pathology. In an August 1997 treatment record he had a mild scar of his right eye. In a June 1998 treatment record he reported having headaches and having strain and burning of both eyes. He was prescribed artificial tears for 14 days. In a December 1998 treatment record he reported normal vision during the day, but poor vision at night with blurriness when looking at incoming lights of other cars. In a separate December 1998 treatment record he reported worsening vision when he experienced headaches. In a January 1999 STR he reported that, during the day his vision was normal, but at dawn and sunset his vision was poor in both eyes. He was diagnosed with bleached photo receptors secondary to incoming lights. There was no evidence of any retinitis pigmentosa or other pigmentary retinopathy, optic atrophy, or glaucoma. It was noted that he previously had taken medication for his malaria that, at times, could cause nyctalopia, or night blindness, but that he was not currently using it. The examiner made a note to rule out a Vitamin-A deficiency. During a March 1999 medical examination the Veteran noted that he wore corrective lenses. In a March 2002 VA treatment record he was diagnosed as having myopic astigmatism. During his January 2004 military retirement physical he was given a vision test, which he passed. During a February 2004 examination he was noted to have myopia in both eyes; he resultantly wore corrective glasses. Generally speaking, mere refractive errors of the eyes - including myopia, presbyopia, and astigmatism, and congenital or developmental defects are not diseases or injuries within the meaning of applicable legislation for VA compensation purposes. So service connection is usually expressly precluded as a matter of law. 38 C.F.R. §§ 3.303(c), 4.9 (2012). VA's General Counsel has held, however, that service connection may be granted for diseases (though not defects) of congenital, developmental or familial origin if the evidence as a whole shows that the manifestations of the disease in service constituted "aggravation" of the disease within the meaning of applicable VA regulations. VAOPGCPREC 82-90 (July 18, 1990); 38 C.F.R. §§ 3.303(c), 3.306. The General Counsel indicated support for this position could be found in VA's regulations, themselves, noting that sickle cell anemia, although a familial disease, was included for rating purposes in the Schedule for Rating Disabilities (Rating Schedule). Also according to the VA General Counsel's opinion, although service connection cannot be granted for a congenital or developmental defect, such a defect can be subject to superimposed disease or injury, and if that superimposed disease or injury occurs during military service, service connection may be warranted for the resultant disability. VAOPGCPREC 82-90. Thus, to allow for proper legal analysis of a Veteran's claim as it pertains to the claimed disability, medical clarification may be necessary as to whether the Veteran's condition is a congenital or developmental "disease" or "defect." See id; Quirin v. Shinseki, 22 Vet. App. 390, 395 (2009). If the claimed disorder is a disease, an opinion may be required as to whether it was as likely as not aggravated by the Veteran's period of active service beyond its natural progression. If the claimed disorder instead is a defect, an opinion may be required as to whether it was as likely as not subject to a superimposed disease or injury during military service that resulted in disability apart from the congenital or developmental defect. See also Monroe v. Brown, 4 Vet. App. 513, 514-515 (1993); Carpenter v. Brown, 8 Vet. App. 240, 245 (1995); VAOPGCPREC 67-90 (July 18, 1990). Here, although the Veteran was diagnosed with myopia in service, there is no suggestion this warrants service connection. Id. He has not argued, nor is there evidence suggesting, he had a pre-existing congenital or developmental abnormality that was chronically aggravated during or by his service by a superimposed disease or injury and resulted in additional disability apart from this refractive error. Despite the fact that he was treated during his service for various vision-related ailments, none are shown to be attributable to any event, disease or injury during his service or to have resulted in chronic residual disability. Since separation from service, he has been treated both privately and by VA for vision-related problems. In a January 2006 private treatment record he was diagnosed with conjunctivitis of both eyes. In a January 2007 VA treatment record he complained of sensitivity to light in the morning and feeling like he had sand in his eyes at the end of the day. He was diagnosed with DES/blepharitis and told to use warm compresses and artificial tears and perform lid scrubs. In an October 2008 private treatment record he reported chronic dry eyes. In a January 2009 private treatment record he complained of decreased night vision and dry eyes. There were constricted fields of the left eye noted. During his October 2011 VA examination he reported having red, irritated, dry eyes with poor night vision. He wore eyeglasses and used ocular lubricants 4 times a day. The examiner diagnosed myopia, which was corrected to good vision. He noted the Veteran had a history of uveitis/iritis while on active duty, but which since had resolved without sequelae (i.e., residuals). With regards to the decreased night vision, the examiner found no known etiology for the condition and there was no evidence of pigmentary retinal pathology during service or currently. Although the Veteran was diagnosed with dry eyes on active duty and treated with ocular lubricants, there was no evidence of ocular sequelae other than redness/injection to the eyes that was not present during that VA examination. Ultimately, then, the examiner found no active ocular pathology at the time of that evaluation. See also November 2011 statement from physician noting claims file was reviewed for the pertinent medical history. Thus, even though the Veteran was treated for various eye-related disorders while in service, there is no competent and credible evidence that residuals of those disorders still exist, including since the filing of this claim, or that he suffers from a different vision disorder - that is, apart from his refractive error - which could warrant the granting of service connection. Notably, the first and indeed perhaps most fundamental requirement for any service-connection claim is that the Veteran has to initially establish he has the claimed condition. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it; without this minimum level of proof, there can be no valid claim). In Brammer, the Court noted that Congress specifically limited entitlement for service-connected disease or injury to cases where such incidents had resulted in a disability. See also Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) [service connection may not be granted unless a current disability exists]. A "current disability" means a disability shown by competent evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). Without a current diagnosis of a ratable disability, the Board cannot grant service connection. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997) (indicating VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability). But see, too, McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (clarifying that this requirement that a claimant have a current disability before service connection may be awarded is satisfied when a claimant has the disability at the time the claim is filed or during the pendency of the claim, even if the disability resolves prior to VA's adjudication of the claim). Here, though, even to the extent the Veteran may have current eye disability, it has not been attributed by competent and credible evidence to disease, injury or event during his military service. Hence, there is not attribution of this disability to his service. Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). While the Board sincerely appreciates his honorable service, there is no competent and credible evidence, so no ultimately probative evidence, indicating he suffers from an eye-related disorder because of his military service or that incepted during his service and continues to the present day. He has not offered any competent and credible lay evidence or medical opinion in support of his claim tending to show he suffers from such a disability. To the contrary, the greater weight of the evidence is against his claim. Accordingly, his claim must be denied. Right Hand Disorder, CTS, and Residuals of a Right Index Finger Injury The Veteran also contends these disorders are related to his military service and, thus, are service-connected disabilities. The Board has reviewed his STRs for evidence pertaining to his right hand claims. During his entrance examination in March 1984 he was not diagnosed with any defects of his right hand or index finger, nor did he report any complaints of problems. In May 1986 he complained of pain in his right index finger after injuring it in a football game. X-rays showed an avulsion fracture at the base of the middle phalanx of the right index finger. He was diagnosed with a volar plate fracture and instructed to tape his fingers for the next two weeks. His right hand was X-rayed in August 1986 after he reported dropping something on his hand while loading a truck. There was a deformity of the fifth metacarpal that was determined to probably be an old healed fracture. There was soft tissue swelling, but no acute fracture. In an October 1995 treatment record the Veteran's right hand was X-rayed and there was no then recent fracture seen. There was an old healed fracture of the fifth metacarpal, distal shaft. During a periodic health examination in March 1999 he reported no problems with his right hand, including his index finger. During his military retirement examination in February 2004 the Veteran did not complain about his right hand or right index finger. He did report numerous other health problems - including lower back pain, chronic headaches, hypertension, bilateral shoulder dislocations, recurring ankle sprains, coronary artery disease, left leg injuries, and scars. He specifically remarked that he did not have impaired use of his hands. He clearly was treated for right hand and index finger injuries in service, and he did not have any pre-existing disability. However, even accepting that for all intents and purposes he did not have these conditions when entering service, there is no suggestion he now has chronic residuals of those right hand and right index finger injuries in service, including in the way of CTS. And, again, it is not enough merely enough to show he had these claimed conditions or injuries during his military service, as there also must be current disability and attribution of this current disability to his military service, including, here, to those injuries in service, and there is not this required linkage. See Maggitt v. West, 202 F.3d 1370, 1375 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); and Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998). Following separation from service, in an August 2005 X-ray report there were no acute fractures noted. There was minimal spurring on the 3rd through 5th fingers and the soft tissues were unremarkable. The private treatment provider could not rule out early osteoarthritic changes in the 3rd to 5th fingers. But there were no abnormalities of the index finger or other areas of the right hand shown. In a December 2005 private treatment record the Veteran reported pain in his right wrist that he said had existed for one week with tingling and numbness in his middle fingers. His wrist showed abnormalities on the Phalen and Tinel test. He was diagnosed with CTS and instructed to wear splints. During his more recent August 2011 VA compensation examination he reported that he had injured his right index finger in service and since had reinjured it on multiple occasions. He reported wearing a splint on at least two occasions due to his index finger injuries. He also stated he had numbness of his right thumb and index finger whenever he wrote something. With regards to his right hand, he indicated that he had injured it during his service when someone stepped on it while playing football, and that he had reinjured it when a box fell on it. He also stated he had injured his hand again while boxing, but did not go to sick call for it. He additionally mentioned injuring his wrist in service, but said he did not seek medical attention. He denied numbness in his right hand or wrist, but stated that he did wear a wrist brace on occasion. See also July 2010 Board hearing transcript. The VA compensation examiner who evaluated him in August 2011 concerning this claim reviewed the STRs and performed an objective physical examination. She found no loss of range of motion and no ankylosis of the right index finger. On X-ray there were no arthritic changes shown. There was an old fracture of the little finger noted. The soft tissue was normal. The Veteran's right wrist was found to be normal on examination and X-ray, as well. There was no evidence of CTS as he had a negative Tinel and Phalen test. The examiner ultimately determined the Veteran had a normal examination and no arthritis or fracture of the right hand or index finger in the way of current disability. The examiner opined it was less likely than not that the Veteran had residuals of a right index finger injury. She also opined that he did not have CTS as a result of injuries during his service. There was no evidence of abnormality of his right index finger, hand, or wrist. The numbness he reported was found to be more consistent with effects of excessive compression fingers on a pen or pencil and not consistent with CTS. In deciding claims, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion). In this case, the Veteran was diagnosed with CTS of the right wrist in a December 2005 private treatment record. The examiner based this opinion on the Veteran's complaints of right wrist pain and numbness. The examiner did not relate this condition to the Veteran's military service, including especially to the injuries he had sustained during his service. There was no further follow up for this condition. The August 2011 VA examiner performed a physical examination and interviewed the Veteran. Ultimately she found that he did not have CTS and that his complaints were more likely related to gripping a pen or pencil too hard. He also denied any numbness in his right hand or wrist during that examination. The Board is not competent to supplement the record with its own unsubstantiated medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). As such, it relies on the opinions of medical examiners. The Veteran denied numbness in his right wrist and the Tinel and Phalen testing was negative for CTS during his August 2011 VA examination. So the Board is assigning more probative weight to the August 2011 VA examiner's opinion that the Veteran is not currently suffering from a right wrist or hand disorder, including especially CTS, inasmuch as the testing specific to this disorder was unremarkable. Moreover, although the Veteran was treated for right index finger and right hand injuries in service, there is no competent and credible evidence that he has residuals of those injuries or a chronic disorder as a result or consequence. During his August 2011 VA examination he was found to have a normal right index finger, hand, and wrist. As already explained, without confirmation of current disability, the Board cannot grant service connection because there is no present disability to relate or attribute to his military service. To prevail on the issue of service connection, a current disability must have existed on or after the date of application for that disability. See 38 U.S.C.A. § 1110; see also Degmetich, supra; McClain, supra. While the Board sincerely appreciates the Veteran's very meritorious service, there is no competent and credible evidence that he suffers from a right hand or wrist disorder as a consequence or that he has chronic residuals of any right index finger injury during his service. He has not offered or identified any such evidence or provided any medical opinion supporting his claim that he suffers from these claimed disabilities on account of his service. Instead, the weight of the evidence is against his claims, so they must be denied. Increased Rating Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. All reasonable doubt material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 4.3. His entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, entitlement to compensation already has been established and increase in disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all of the evidence of record, the more critical evidence consists of the evidence generated during the appeal period. But that said, the Board nonetheless must evaluate the medical evidence since one year prior to the filing of the claim for a higher rating to determine whether different ratings should be assigned for distinct periods of time based on the facts found, in other words, whether the rating should be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007). So this concept of a "staged" rating is not just applicable to initial ratings, see Fenderson v. West, 12 Vet. App. 119, 125-26 (1999), but also, as here, according to Hart, to established ratings. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The provisions of § 4.59 relating to painful motion are not limited to arthritis, so must be considered when raised by the claimant or reasonably by the record, even in non-arthritis contexts. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The factors involved in evaluating and rating disabilities of the joints include weakness, fatigability, incoordination, restricted or excess movement of the joint, or pain on movement. 38 C.F.R. § 4.45. Functional loss due to pain is rated at the same level as functional loss where motion is impeded. Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limited motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). A finding of functional loss due to pain, however, must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). And, further, if a Veteran already has the maximum rating assignable based on limitation of motion, it is not necessary to consider these provisions. Johnston, supra. Moreover, the Court has clarified that, although pain may be a cause or manifestation of functional loss, pain itself does not constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Id.; see 38 C.F.R. § 4.40. The Veteran contends that a rating higher than 20 percent is warranted for his low back disability. His low back disability has been characterized as a lumbar strain and DDD of the lumbar spine. See April 2008 and October 2012 rating decisions. However, he has consistently been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Under the General Rating Formula for Diseases and Injuries of the Spine, § 4.71a, with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, unfavorable ankylosis of the entire spine warrants a 100 percent rating. Unfavorable ankylosis of the entire thoracolumbar spine warrants a 50 percent rating. Forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine warrants a 40 percent rating. Forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spine contour such as scoliosis, reversed lordosis, or abnormal kyphosis warrants a 20 percent rating. Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height warrants a 10 percent rating. Note (1): Evaluate any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. Intervertebral disc syndrome (IVDS) also is rated under a General Rating Formula. When there are incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months, a 20 percent rating is warranted. IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months warrants a 40 percent rating. IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months warrants a 60 percent rating. 38 C.F.R. § 4.71a, formerly Diagnostic Code 5293 (effective September 23, 2002); now codified since September 2003 at Diagnostic Code 5243. An accompanying note in DC 5243 defines an incapacitating episode as a period of acute signs and symptoms due to IVDS that requires bed rest prescribed by a physician and treatment by a physician. Chronic orthopedic and neurologic manifestations means orthopedic and neurologic signs and symptoms resulting from IVDS that are present constantly, or nearly so. Having considered the evidence of record, the Board finds that the Veteran is not entitled to a rating higher than 20 percent for his underlying lumbar spine disability at any point during the appeal period. He is, however, entitled to additional compensation in the way of separate ratings for his associated neuropathy. With regard to range-of-motion testing, during his November 2007 VA examination he had flexion to 80 degrees, albeit with pain, and extension to 20 degrees, also with pain. During his January 2009 VA examination he had flexion to 40 degrees, with pain, and extension to 10 degrees, with pain. During his most recent August 2011 VA examination, he had flexion to 90 degrees and extension to 20 degrees. There was no additional loss of range of motion on repetition (repetitive testing). There also was no ankylosis. Applying the range-of-motion measurements to the General Rating Formula for Diseases and Injuries of the Spine, the above evidence demonstrates the Veteran is not entitled to a rating greater than 20 percent for the orthopedic manifestations of his lumbar spine disability. An evaluation greater than 20 percent is not warranted as there is not forward flexion of the lumbar spine limited to 30 degrees or less, including when considering his associated pain and its consequent effect on his range of motion. In addition, there is no suggestion of ankylosis of his lumbar spine or of his entire spine (when additionally considering the adjacent cervical segment), and this is true during the entire appeal period. See, e.g., August 2011 VA examination report. Aside from the note in DCs 5235-5242 defining what constitutes ankylosis, consider additionally that it is stiffening or fixation of the joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) citing Dorland's Illustrated Medical Dictionary at 86 (27th ed. 1988) (Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure."); see also Coyalong v. West, 12 Vet. App. 524, 528 (1999). See, too, Lewis v. Derwinski, 3 Vet. App. 259 (1992) [citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)]. Here, while as mentioned there is no disputing the Veteran has some limitation of motion on flexion of his lumbar spine, his motion is not so restricted as to warrant a rating higher than 20 percent, again, even considering his pain, or to constitute or be the functional equivalent of ankylosis, especially considering he apparently continues to have normal extension, and the VA compensation examiners have confirmed as much. But during his November 2007 VA examination the Veteran reported stiffness and weakness with constant pain that traveled down his legs. He stated his pain was an 8/10 in severity, but that it was relieved by rest and medication. On X-ray the lumbar spine was negative for defects. In an August 2008 private treatment record his medical history included intervertebral disc degeneration of his lumbar spine. In a January 2009 private treatment record he was diagnosed with spinal stenosis. During his January 2009 VA examination he reported stiffness and numbness. He also cited pain that he said was constant, crushing, burning, aching, sharp, and squeezing. He said the pain was 10/10 in severity, although relieved by rest and medication. During his most recent August 2011 VA examination, he reported that his lumbar spine pain had worsened and that he experienced numbness in his buttocks and posterior thigh and shooting pain down both his legs after sitting for a prolonged period. He added that some manual work actually helped his back pain and that he could jog for short periods with a back brace and good shoes. He stated that, when flare ups occurred, once a month, he had to miss work. The examiner reviewed X-rays from October 2008 and noted multi-level disc bulges with hypertrophy. It was noted during his November 2007 VA examination that his lumbar spine range of motion was not limited by pain, fatigue, weakness, lack of endurance, or incoordination on repetitive use. During his January 2009 VA examination his joint function of the spine was limited after repetitive use by pain, fatigue, and lack of endurance. That did not, however, result in any additional loss of range of motion. There equally was no limitation from weakness and incoordination. During his August 2011 VA examination the examiner observed the Veteran's lumbar spine disorder caused stiffness and spasms, but there was no weakness or fatigue noted. The Veteran therefore has not shown entitlement to a rating greater than 20 percent for his low back disability when considering the extent of his limitation of motion. This is not the only consideration, however, since a separate evaluation, so additional compensation, may be assigned for associated neurological impairment. Under 38 C.F.R. § 4.124a, Diagnostic Code 8515, pertaining to paralysis of the median nerve, mild incomplete paralysis warrants a 10 percent rating, moderate incomplete paralysis warrants a 30 percent disability rating, severe incomplete paralysis warrants a 50 percent disability rating, and severe incomplete paralysis with marked muscular atrophy warrants a 60 percent disability rating. Similarly, under Diagnostic Code 8520, pertaining to paralysis of the sciatic nerve, mild incomplete paralysis warrants a 10 percent disability rating, moderate incomplete paralysis warrants a 20 percent disability rating, moderately severe incomplete paralysis warrants a 40 percent disability rating, and severe incomplete paralysis with marked muscular atrophy warrants a 60 percent disability rating. There were no neurological defects noted during the Veteran's November 2007 VA examination. During his January 2009 VA examination he specifically denied any loss of bladder control or bowel control. He did however report numbness of his upper and lower extremities. And, notably, the examiner indicated the Veteran had progressive neuropathy (rather than peripheral neuropathy) that was at least as likely as not related to his service-connected low back disability. During the August 2011 VA examination there was no history of urinary or fecal problems, erectile dysfunction, numbness, or other neurological symptoms. He also had no muscle atrophy and normal muscle strength of his hips, knees, ankles, and great toes. He nevertheless has consistently reported numbness in his extremities, and the January 2009 VA examiner attributed this to the Veteran's service-connected low back disability. This progressive (rather than peripheral) neuropathy, then, has been determined to be proximately due to, the result of, or aggravated by this service-connected low back disability inasmuch as it is associated with or part and parcel of this service-connected disability. See 38 C.F.R. § 3.310(a) and (b) and Allen v. Brown, 7 Vet. App. 439, 448 (1995). This in turn provides evidence suggestive of "mild" incomplete paralysis of the sciatic nerve as a result or consequence of the low back disability warranting an additional 10 percent rating for each extremity. But absent evidence of complete paralysis of the median nerve or constant weakness, bowel or bladder impairment, muscle atrophy, or foot drop, a higher rating for this neuropathy is not in order. See 38 C.F.R. § 4.124, Diagnostic Codes 8515 and 8520. During his January 2009 VA examination the Veteran reported incapacitating episodes for 2 days in October and December 2008. During his August 2011 VA examination he specifically denied any incapacitating episodes of spine disease. With respect to the rating criteria based on incapacitating episodes, there is no competent and credible evidence in the record that his lumbar spine disability has required bed rest prescribed by a physician for at least two weeks at any point during the appeal period. This, by definition, is what is required to constitute an incapacitating episode, and even when meeting this definition they must be of a certain specified frequency or duration to warrant a certain rating. This is not shown here, however. The Board acknowledges the Veteran's contentions that his lumbar spine disability warrants an evaluation greater than 20 percent, that is, even aside from the separate 10 percent ratings the Board is granting in this decision for the associated progressive (rather than peripheral) neuropathy. But in determining the actual degree of disability, his lay opinions and observations alone cannot meet the burden imposed by the rating criteria under 38 C.F.R. § 4.71a with respect to determining the severity of his lumbar spine disability and must be considered along with the other evidence of record, including the medical evidence. See Moray v. Brown, 2 Vet. App. 211, 214 (1993); 38 C.F.R. § 3.159(a)(1) and (2) (2012). Further, there is no evidence of exceptional or unusual circumstances to warrant referring this claim for extra-schedular consideration. 38 C.F.R. § 3.321(b)(1). The Court has clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a determination of whether the evidence presents such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, there must be a determination of whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as 'governing norms.' Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating under 38 C.F.R. § 3.321(b)(1). The Board finds no such evidence in this particular instance, however. The Veteran's complaints referable to his lumbar spine disability are considered under the appropriate diagnostic codes. His primary symptoms are chronic pain and resultant limitation of motion. But all of his symptoms are specifically accounted for in the regular schedular rating criteria, including the progressive neuropathy that has been additionally attributed to this disability and the reason the Board is granting separate ratings to compensate him for this. According to 38 C.F.R. § 4.1, generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Indeed, in Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993), the Court reiterated this, noting the disability rating, itself, is recognition that industrial capabilities are impaired. The assigned schedular evaluations for the service-connected DDD of the lumbar spine are adequate and referral for an extraschedular rating is unnecessary. Thun, supra. Furthermore, there is no evidence of any other exceptional or unusual circumstances, such as frequent hospitalizations, suggesting he is not adequately compensated for this disability by the regular Rating Schedule. His evaluation and treatment for this disability has been entirely on an outpatient basis, not as an inpatient, much less frequent inpatient. So extra-schedular referral is not warranted under the circumstances presented. See Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); and VAOPGCPREC 6-96 (August 16, 1996). In light of the above, the Board finds that the Veteran is not entitled to an evaluation higher than 20 percent for his service-connected lumbar spine disability. But he is nonetheless entitled to separate 10 percent evaluations for the associated progressive neuropathy of his extremities under 38 C.F.R. § 4.124, Diagnostic Codes 8515 and 8520. In granting these separate ratings, the Board has resolved all reasonable doubt in his favor; otherwise, the preponderance of the evidence is against his claim. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). ORDER The claim of entitlement to service connection for a vision disorder is denied. The claim of entitlement to service connection for a right hand disorder is denied. The claim of entitlement to service connection for CTS is denied. The claim of entitlement to service connection for residuals of a right index finger injury is denied. The claim of entitlement to a rating higher than 20 percent for the underlying low back disability is denied. Separate and additional 10 percent ratings are granted, however, for the associated progressive neuropathy of the extremities, subject to the statutes and regulations governing the payment of VA compensation. REMAND Unfortunately, the remaining claims require another remand. Although the Board sincerely regrets the additional delay that inevitably will result, it is necessary to ensure there is a complete record upon which to decide these claims so the Veteran is afforded every possible consideration. His claim of entitlement to service connection for residuals of a right little finger injury was denied in a December 2008 rating decision. In response he submitted a timely notice of disagreement (NOD) later in December 2008. 38 C.F.R. § 20.201. In that December 2008 rating decision the RO also assigned an increased evaluation of 30 percent for his migraine headaches, retroactively effective from November 8, 2007. He then in response submitted a timely NOD in January 2009 as to the effective date assigned for the 30 percent evaluation. The RO has not however provided him a statement of the case (SOC) regarding these claims of entitlement to service connection for residuals of a right little finger injury and entitlement to an effective date earlier than November 8, 2007, for the grant of the 30 percent rating for his migraine headaches. The Court has indicated that the proper course of action in this circumstance is to remand, rather than merely refer, the claims to provide the Veteran this required SOC and to give him opportunity, in response, to complete the steps necessary to perfect his appeal of these claims to the Board by also filing a timely substantive appeal (VA Form 9/equivalent). See Manlincon v. West, 12 Vet. App. 238 (1999). The Veteran's claim of entitlement to a rating higher than 30 percent for his migraine headaches is clearly impacted by the outcome of his claim of entitlement to an effective date earlier than November 8, 2007, for the grant of the higher 30 percent rating for this same disability. Therefore, these claims are "inextricably intertwined". Harris v. Derwinski, 1 Vet. App. 180 (1991). These claims therefore must be adjudicated concurrently to avoid piecemeal decisions on claims with common parameters. See also Holland v. Brown, 6 Vet. App. 443, 446 (1994); Parker v. Brown, 7 Vet. App. 116 (1994); Ephraim v. Brown, 82 F.3d 399 (Fed. Cir. 1996); and Smith (Daniel) v. Gober, 236 F.3d 1370, 1373 (Fed. Cir. 2001) (Where the facts underlying separate claims are "intimately connected," the interests of judicial economy and avoidance of piecemeal litigation require that the claims be adjudicated together). Accordingly, these remaining claims are REMANDED for the following additional development and consideration: Provide the Veteran an SOC concerning his claims of entitlement to service connection for residuals of a right little finger injury and entitlement to an effective date earlier than November 8, 2007, for the grant of the 30 percent rating for his migraines. Advise him that he still needs to file a substantive appeal (VA Form 9 or equivalent statement) in response to this SOC to complete the steps necessary to perfect his appeal of these additional claims to the Board. Only if he does should these claims be returned to the Board for further appellate consideration. His additional claim of entitlement to a rating higher than 30 percent for his migraines is inextricably intertwined, so also take appropriate action concerning this claim. He has the right to submit additional evidence and argument concerning these claims the Board is remanding. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs